Another voice in the crowd: the challenge of changing family planning and child feeding practices through mHealth messaging in rural central India

Abstract

Introduction: Kilkari is one of the world's largest mobile phone-based health messaging programmes. Developed by BBC Media Action, it provides weekly stage-based information to pregnant and postpartum women and their families, including on infant and young child feeding (IYCF) and family planning, to compliment the efforts of frontline health workers. The quantitative component of a randomised controlled trial (RCT) in the Indian state of Madhya Pradesh found that exposure to Kilkari increased modern contraceptive uptake but did not change IYCF practices. This qualitative research complements the RCT to explore why these findings may have emerged.

Methods: We used system generated data to identify households within the RCT with very high to medium Kilkari listenership. Mothers (n=29), as well as husbands and extended family members (n=25 interviews/family group discussions) were interviewed about IYCF and family planning, including their reactions to Kilkari's calls on these topics. Analysis was informed by the theory of reciprocal determinism, which positions behaviour change within the interacting domains of individual attributes, social and environmental determinants, and existing practices.

Results: While women who owned and controlled their own phones were the Kilkari listeners, among women who did not own their own phones, it was often their husbands who listened. Spouses did not discuss Kilkari messages. Respondents retained and appreciated Kilkari messages that aligned with their pre-existing worldviews, social norms, and existing practices. However, they overlooked or de-emphasised content that did not. In this way, they reported agreeing with and trusting Kilkari while persisting with practices that went against Kilkari's recommendations, particularly non-exclusive breastfeeding and inappropriate complementary feeding.

Conclusion: To deepen impact, digital direct to beneficiary services need to be complimented by wider communication efforts (e.g., sustained face-to-face, media, community engagement) to change social norms, taking into account the role of socio-environmental, behavioural, and individual determinants.

Keywords: child health; health education and promotion; health services research; health systems; public health.

Figure 1

The reciprocal interaction of individual, social–environmental and behavioural determinants.

Figure 2

Visual representation of qualitative respondent data set.

Figure 3

How individual, socio-environmental and behavioural factors interact to support the persistence of breastfeeding, a Kilkari recommended behaviour.

Figure 4

How individual, socio-environmental and behavioural factors interact to support the persistence of non-exclusive breastfeeding, a Kilkari contraindicated behaviour.

Figure 5

How individual, socio-environmental and behavioural factors interact to support the persistence of giving dal ka paani and small portions of food during complementary feeding, which are Kilkari contraindicated behaviours.

Figure 6

How individual, socio-environmental and behavioural factors interact to support the avoidance of modern reversible family planning and male sterilisation.

Figure 7

How individual, socio-environmental and behavioural factors interact to potentially enable Kilkari to influence the use of modern reversible family planning.